Pattern of Antidepressant Use in Bipolar Disorder
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Q: I was dx last April and at the time I was pregant. So they had put me on Paxil for about 3 months it worked and so I d/c'd it. Then after the baby, they tried Nuerotin. Had to d/c that because of getting motion sickness so bad I needed some thing to counter that. I have been on Lithium since July,although it was making me sick it was tolorable. So then after I seem to be stable a bit the tried the Welbutrin on Oct. That made me sick again very bad and some thing happened with the lithium now that has beed d/c'd as well. I was placed on Zyrmax I believe it is (anti-psycotic) cause the voice calling my name is saying a little more and I had also gone as far as writing a suicide note. Now with Bipolar,PTSD,and Anxiety and now who knows what else I believe they are getting to an impass with. They just can't get me stable.I am getting sick of the drugs making me sick and at the same time being sick of having being this way. So what now?

Dear Carolyn --
Of course I can't tell for sure but your experience may illustrate a pattern I've seen enough to really scare me about antidepressants in bipolar disorder: lithium, somewhat stable, add antidepressant, something really bad happens, now lithium doesn't work or isn't enough any more.  So I hope at least your experience might serve as a warning to others about adding antidepressants in bipolar disorder.

As for "what now", well, I wouldn't presume to tell you just what to do, but there are some general guidelines that might apply to you given your experience so far as you relate it here.  They are my two most basic principles of bipolar med' management:

#1.  Rely on mood stabilizers.  In your case this means keep sampling around the mood stabilizer family.  There are now at least 5 clearly recognized med's in this group: lithium, Depakote, carbamazepine (Carbatrol, Tegretol), lamotrigine and topiramate.  Only the last is still just a little uncertain.  That leaves you four "for-sure's".  Try them all at doses you can tolerate, and try mixing at least 3 together if that's what it takes for symptom control (assuming, you see, that the low-dose strategy, defined by what you can tolerate without too much in the way of side effects, keeps you from really having trouble with med's despite their number).

#2.  Watch out for antidepressants.  Basically the only time I feel comfortable using an antidepressant anymore, in people with clear bipolar disorder, is if they have a pure depression.  That means sleeping 10-14 hours a day -- no insomnia allowed, that's a hypomanic symptom.  It means no energy/anxiety symptoms -- only fatigue, listlessness, low energy, low motivation.  I find this "pure" form pretty rare, anymore.  Most of my patients, anyway, have mixed states -- and that' precisely where to watch out for antidepressants.  If I use them at all, it's very low doses, and start the taper off almost as soon as some response appears; only if the person repeatedly becomes depressed doing that would I consider staying on the antidepressant.

So, that's the strategy: keep trying, keep going, you have a long way to go to exhaust all the possibilities.  It's hard to search and search, but you often find something that really works.

Dr. Phelps

Published October, 2000

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